Quality Improvement 3.0
Berwick and Cassel have reviewed the National Academy of Medicine’s impact on the quality improvement effort in the US with emphasis on their reports “To Err is Human” (1999) and “Crossing the Quality Chasm,” (2001.) Reviewing the 20 years since these reports they conclude:
“Focal progress in quality improvement is undeniable…But wholesale, systemic improvement of quality of care has proven difficult to bring to scale. Improvements tend to remain local rather than spreading. Many health care leaders, distracted by financial pressures, have diminished their strategic focus on improving quality.”
A following article by McGlynn looks at why this is so. She reviews the state of the art using the classic triad of structure, process, and outcome, concluding:
“I believe we should start by creating the financial and organizational conditions for changing care delivery from a reactive, fragmented enterprise to one that is coordinated and longitudinal, reflecting the need for systems that can effectively manage chronic disease…enabling patients to achieve their health goals alone and in partnership with health professionals.”
A different emphasis was made by McWilliams, who noted the professionalism displayed by clinicians responding to the demands of the pandemic. He considers this a resource that needs to be conserved and not squandered. “We should ask how the professionalism of our clinicians can be more effectively tapped and supported.” He began by considering “physician agency” and quality measurement. Physician agency is the notion the physician acts as the patient’s agent in determining a diagnosis and a treatment plan.
“Empirical observations that physicians can be misinformed, unaware of evidence, subject to biases, and influenced by financial incentives upended physicians’ long-standing position as unquestioned and self-regulating authorities. With these shortcomings exposed, consensus emerged that physicians could no longer be solely entrusted to know and do what is best for their patients. For more than 2 decades we have deployed quality measures hoping to overcome physicians’ limitations. In general, quality improvement strategies can be categorized based on their reliance on performance measures and involvement of the payment system.”
McWilliams notes the focus on measurable markers of healthcare can divert resources from harder to measure, but important, aspects of care, or what I have discussed as the quality paradox. Since process measures detect the symptoms, but not necessarily the cause of the dysfunction, though, it is possible (probable?) that the system will be gamed. Risk adjustment is necessary to make valid comparisons, but no system has emerged that seems to do this as yet.
“As an enormously complex construct, quality cannot be measured in its entirety. The bulk of reimbursement will always be unrelated to quality. Paying on numerous measures further weakens incentives to improve on any one dimension, whereas paying on fewer may support stronger incentives for meaningful change but only for a narrow slice of quality.”
He suggests, instead, that efforts be made to target problems of information or motivation when providers are acting as agents, but notes the methodology is untested. He noted that when asked, physicians usually have strong opinions about which of their peers is outstanding, either good or bad. But this approach is rarely used to determine either exemplars or those needing corrective action. He also noted physicians have and act on tacit knowledge, but we don’t know how that relates to the quality of care, and collective wisdom is often better than individual opinion but this is rarely explored.
To tap intrinsic motivation, he argued that professional goals and organizational goals needed to be aligned. He argued for competition as a driver for improvement, but notes market consolidation is a real barrier that is getting worse. Organizational management must also include components specifically designed to support professionalism and cites organized peer pressure as one example.
I started using formal CQI processes in the dialysis unit in 1986 and even wrote an editorial in 1992 arguing it was the wave of the future. But I was using the methods for local purposes, improving care the team and I marked as needing work. We did not have to report the data and we were mostly comparing outcomes with our previous results. I think of this as CQI 1.0. It was fun and rewarding. Then the institutionalization and monetization outlined above took over and the fun vanished. “Fixing the numbers” rather than “improving the care” took over as the focus, which I call CQI 2.0. Even the leading advocates cited concede we have expended a lot of money and effort with limited results. Worse, the efforts have contributed to the fragmentation of care and the loss of focus on the patient.
So, are we ready to enter CQI 3.0? If so, what should we learn? First, we must disabuse ourselves of the notion that there is one approach that addresses all issues. We need to measure, but we need to understand that any current batch of measures is imperfect, so performance measures are needed to establish an acceptable range of performance. Second, we need to overcome the supposition that variation is bad and unexplained does not necessarily mean it is wrong. Third, we must acknowledge we are taking care of people, not machines—they are always free to reject our advice. This is the essence of patient autonomy, but it makes the numbers worse. Lastly, we need to realize the limits of removing the bad apple approach. What if we rewarded the stars instead? If most people most of the time want to do the right thing, what would happen if we encouraged clinicians always to put the needs of the patient first?
30 August 2020
 Berwick DM, Cassel CK. The NAM and the Quality of Health Care—Inflecting a Field. N Engl J Med 2020;383(6):505-508. doi:10.1056/NEJMp2005126.
 McGlynn EA. Improving the Quality of U. S. Health Care—What Will It Take? N Engl J Med 2020;383(9):801-803. doi:10.1056/NEJMp2022644.
 McWilliams JM. Professionalism Revealed: Rethinking Quality Improvement in the Wake of a Pandemic. NEJM Catalyst Innovations in Care Delivery 2020:05. doi: 10.1056/CAT.20.0226. Accessed 20 August 2020 at https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0226.
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